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A Validated Strategy to Reduce Error in
Electronic Orders
Session # 129, February 13, 2019
Zane Last, PharmD, MBA
Director - Healthcare Analytics & BI
SBH Health System
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Zane Last, PharmD, MBA
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Objectives Decrease Near-Miss Orders
Methods CPOE Hard Stop
Process Review
Assessing Error Rates
Results
Intervention
Outcomes
Implementation Considerations
References
Agenda
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Diagnose number of near-miss wrong patient
orders in a CPOE system with a Hard-Wired EHR
process
Develop strategies to implement a CPOE Double
ID system alert
Use strategy to assess wrong patient, right order
near-miss
Learning Objectives
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Decrease the number of near-miss wrong-patient orders in a
computerized physician order entry (CPOE) system
CPOE systems are commonly used to place orders
1-4
Prevention of medication errors and medication safety
Production or exacerbation of new medication errors
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Wrong Patient CPOE Errors:
Significant morbidity and mortality
8-10
Efforts to reduce Wrong Patient CPOE errors in our health system led us
to the development of an alert
Verification of the patients identity by the ordering physician at the
time of CPOE
Objective
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SBH is the Oldest Continuing Healthcare Facility in the NY City Area
Located in the Bronx, Celebrating its 153
rd
Anniversary
A Not-for-profit, Nonsectarian teaching hospital
Payer Mix of 90% Medicaid/Medicare
Acute Care:
422 certified hospital beds
Level 2 trauma center
NY State-designated stroke and AIDS center
Over 88,000 emergency room visits annually
Over 17,000 hospital discharges
SBH Health System - Overview
Ambulatory Care:
Over 400,000 outpatient visits annually
NCQA Patient-Centered Medical Home
designation
One of largest providers of Mental
Health services in the Bronx
19 programs with more than 160,000
visits annually
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A CPOE, hard stop, alert was built and implemented:
Ordering clinicians were prompted to reaffirm the patients
identity
Entering the patient’s initials and year of birth prior to
placing an order became mandatory
Methods
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Multidisciplinary Stakeholder Team
Senior Leadership
ED Leadership
Front-Line Staff
Representation from all disciplines involved with the CPOE
Process
Nursing
Pharmacy
Radiology
Process Review for CPOE ordering
Clinical Laboratory
Information Technology
Analytics
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Factors Contributing to CPOE Patient ID Errors
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We utilized a Retract and Reorder tool developed by Adelman et
al
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Measures the frequency of near-miss wrong-patient order
errors before and after implementation of the alert
Flags orders placed for one patient, erased, then added to
another patient’s file by the same clinician
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within a 10 minute time
frame
Identifies near-miss errors self caught by the provider before
causing harm to the patient
Closely related to other errors that may reach the patient
Assessing Error Rates
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The ID re-entry function decreased near-miss wrong-patient
orders in our ED by 35% during the 8-week pilot period. The
system was also successful in helping to decrease the percentage
of all CPOE near-miss events by 49%.
October December 2014
231 near-miss, wrong-patient orders throughout the health
system
37% occurring in the Emergency Department
Approximately 1 near-miss per day in the ED
Results
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Mandatory ID re-entry functionality:
Prescriber required to enter the patient’s initials and year of
birth at the beginning of order entry
In line with TJC’s National Patient Safety Goal
Two patient identifiers when providing care, treatment,
and services
Intervention
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1
st
Alert: Initiating a New Order
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2
nd
Alert: Incorrect Entry
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3
rd
Alert: Repeat Error
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Implementation in our ED: November 3, 2015
Error Rates: 35% reduction
Prior to intervention: 6.125 events per week
After intervention: 4 events per week
Near miss ID Errors in the ED relative to system wide errors
Decreased from 37% to 19%
Similar to results by Adelman et al
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Resident and Attending staff corroborate that ID functionality
does in fact bring awareness to wrong patient selections
Time studies indicate:
CPOE ID re-entry added 6.2 seconds to an order entry
session Experience brings this down to 4.0 seconds
Outcomes
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Other IT initiatives going live at the same time
Locations for implementation
Pilot location: Emergency Department
Additional Location(s): ICU
Errors during go live
No alerts or missing alerts
Untrained providers experiencing the alert
Providers locked out of the system after incorrectly
identifying a patient
Implementation Considerations
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Work-arounds that can lead to identification errors
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Providers blindly utilize the patient header to enter patients
initials and year of birth by viewing window behind alert
screen
Workplace interruptions a significant factor
Create no interruption zones
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Multiple sign on sessions
Clinicians utilizing multiple EHR sign-on sessions
Leading to confusion when toggling between patients on
multiple screens
Errors Can Still Occur!
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An alert that requires the prescriber to enter the patient’s initials
and birth year is effective in decreasing wrong-patient orders in
the SBH Health System’s Allscripts CPOE system
Conclusion
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1. Bates, DW, Leape L, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention
of serious medication errors. JAMA 1998;280:131116.
2. Bates, DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am
Med Inform Assoc 1999;6:31321.
3. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems
on medication safety: a systematic review. Arch Intern Med 2003;163:140916.
4. Reckmann, MH, Westbrook JI, Koh Y, et al. Does computeized provider order entry reduce prescribing errors for hospital
inpatients? A systematic review. J Am Med Inform Assoc 2009;16:61323.
5. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors.
JAMA 2005;293:1197203.
6. Broder C. Study: CPOE can increase risk of medication errors. Health IT News. March 9, 2005.
7. Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors: analysis of reported
errors and vulnerability testing of current systems. BMJ Qual Saf 2015;24:26471.
8. Adelman, JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic orders: a
randomized controlled trial. JAM Med Inform Assoc 2013;20:30510.
9. Yang A, Grissinger M. Pennsylvania Patient Safety Authority. Wrong-patient medication errors: an analysis of event
reports in Pennsylvania and strategies for prevention. PA Patient Saf Advis 2013 June;10:419.
10. Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry
system. Ann Emerg Med 2015;65:67986.
11. Anthony K, Wiencek C, Bauer C, et al. No interruptions please: impact of a No Interruption Zone on medication safety in
intensive care units. Crit Care Nurse 2010;30:219.
12. Institute for Safe Medication Practices. Side tracks on the safety express. interruptions lead to errors and unfinished…wait,
what was i doing? 29 Nov 2012. Accessed at: www.ismp.org/Newsletters/acutecare/showarticle.aspx?id=37
References
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Zane Last, PharmD, MBA
zlast@sbhny.org
linkedin.com/in/zane-last-pharmd-mba
Questions